Healthcare Provider Details

I. General information

NPI: 1972871333
Provider Name (Legal Business Name): HAVANA PHARMACY AND MEDICAL SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 03/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 S HAVANA ST UNIT HJ
AURORA CO
80012-5004
US

IV. Provider business mailing address

1555 S HAVANA ST UNIT HJ
AURORA CO
80012-5004
US

V. Phone/Fax

Practice location:
  • Phone: 303-750-3600
  • Fax: 303-750-3607
Mailing address:
  • Phone: 303-750-3600
  • Fax: 303-750-3607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number836
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: GEORGE SACKEY
Title or Position: PHARMACIST/OWNER
Credential: RPH
Phone: 303-668-0032